- WebCafé home
- Newly Diagnosed
- Treatment Options
- Non-Invasive blc
- Invasive bladder cancer
- Upper tract TCC
- Metastatic cancer
- Clinical trials
- Survival Guides
- Resources USA & Canada
- Resources Europe
- Clinical trials
- Alternative medicine
- Financial help
- About Us
Michael C. Carr, M.D., Ph.D.
Michael E. Mitchell, M.D.
University of Washington School of Medicine
Children's Hospital and Regional Medical Center
Augmentation cystoplasty has been described using ileum, cecum or sigmoid
colon,1-3 as isolated flaps or in various shapes, combinations
and quantities. This experience led to the creation of large and compliant
The use of the stomach has proven to be invaluable in reconstructive
Despite the successes with gastric augmentation and bladder substitution,
the ideal augmentation would not introduce either bowel or gastric mucosa
into the urinary tract. Metabolic complications, urolithiasis, mucus production,
spontaneous perforation, and even malignant degeneration would be eliminated.
A urothelial-lined bladder with gastrointestinal tract muscle augmentation
of the detrusor muscle was attempted as early as 1955.12
Other demucosalized intestinal segments have also been used in several
other studies.13, 14 Another surgical
attempt to preserve transitional epithelium is detrusorrhaphy or autoaugmentation.15
The detrusor, however, is potentially replaced with fibrous tissue or
whatever adheres to urothelium, which may result in inadequate bladder
volume or poor compliance. An autoaugmentation gastrocystoplasty or demucosalized
gastric flap procedure (DAWG) uses a full thickness urothelial graft in
conjunction with a raw inner surface of incorporated stomach muscle/submucosa.16
Patient selection for gastrocystoplasty is no different than for any
A long midline incision is made from the symphysis pubis to the xyphoid
The stomach is brought well into the surgical field. It is helpful to
The electrocautery and bipolar electrode can be used to do this very
Total Bladder Replacement with the Wedge Flap
Total bladder replacement with stomach is possible using the wedge flap. Following removal of the staples, the apex of the wedge is simply sutured to the urethra. This may be feasible in the patient with an intact urethra (bladder replacement). The urethra may be sutured to the apex of the flap which can be tubularized to provide a nice bladder neck. Several options are available for patients requiring construction of a catheterizable reservoir. A distal ureter may be used as a catheterizable channel. The ureter can be tunneled in between mucosa and muscularis of the reservoir wall to provide continence. This is generally possible only in the cloacal exstrophy population. The appendix, as well, has been used in a similar manner. The construction of a bladder tube, using a strip of the gastric flap, has been used successfully. The tube is nippled into the reservoir to provide continence. This has resulted in a channel which is catheterizable and dry. Our preference, however, would be to use a tunnel technique for dryness with the construction of a gastric reservoir. In bladder replacement it is usually most convenient to open the wedge completely and suture the posterior tip (which usually is the anterior apex of the wedge) onto the urethra. Subsequently, with the gastric segment open, ureteral reimplantation is easily performed in much the same way that a tunneled reimplant would be performed in the bladder. A plane between the mucosa and muscularis of the gastric flap is usually easily defined with sharp dissection. The anterior portion apex is then sewn to the anterior portion of the urethra and the lateral aspects of the wedge are then closed using a two layer closure of running 3-0 Monocryl and Vicryl. A suprapubic tube (Malecot catheter) may be brought through the gastric tissue, but if such is done, it would be advisable to suture the wall of the gastric reservoir to the anterior abdominal wall as would be the case with a gastrostomy. This prevents intraperitoneal leakage when the tube is subsequently removed. A catheterizable stoma should be constructed flush with adjacent tissue and in such a manner that catheterization can be performed without difficulty. A small V-flap of skin and spatulation of the catheterizable channel works well. If catheterization is difficult in the operating room, it will be impossible out of the operating room.
Demucosalized Gastric Flap Procedure Augmentation of a bladder after
detrusorrhaphy with demucosalized gastric flap is similar to gastrocystoplasty.
The bladder is approached initially. It is helpful to have a Foley catheter
in the bladder connected to a reservoir of irrigating saline that can
be raised or lowered to fill or empty the bladder as desired. The bladder
is filled to a pressure of approximately 20cm of water and the detrusor
incised in the midline sagittal plane. Great care is taken to preserve
the transitional epithelium in finding the plane between the transitional
epithelium and muscularis. It is easiest to use blunt and sharp dissection
with the bladder full to do this. If no holes are made in the epithelium,
this usually goes very easily. Once a hole is made and the bladder is
decompressed it becomes very difficult to dissect the plane between the
transitional epithelium and the bladder muscularis. We usually remove
muscularis from two-thirds to three-quarters of the anterior and lateral
wall of the bladder. The bladder is emptied by lowering the reservoir,
followed by gentle packing with moist
A gastric flap is obtained. Before it is brought into the pelvis, however,
The management of the gastrocystoplasty patient is similar to that of any patient with intestinal augmentation. Mucus is generally not a problem, but irrigation of the bladder should be routinely performed initially. All patients are maintained on intravenous antibiotics and then converted to chronic suppression for at least two months after surgery. H2-blockade, usually consisting of Ranitidine (1mg/kg q8h), is continued for one to two months postoperatively. If the patient then develops dysuria or perineal pain, the Ranitidine is resumed until the symptoms resolve or the hematuria improves. Removal of the suprapubic tube is dependent on the ability of the patient to empty the bladder. A trial period of at least one week of continuous clamping is usually wise while the patient begins to void or intermittent catheterization is reinstated. Finally, patients with anuria, or dilute urine, may rarely require irrigation with phosphate buffer if low pH and irritation is observed. Infection is less common with the gastrocystoplasty patient, but asymptomatic infection is usually not treated unless the organism is felt to be significant for potential stone formation or pyelonephritis. Serum electrolytes should be followed periodically.
Early and Late Complications
Our initial experience in 80 patients with stomach augmentation or
Patients with gastrocystoplasties who lose large amounts of hydrochloric acid, sodium and potassium in the urine may become severely dehydrated and alkalotic. This usually occurs only when patients have significant salt losses from the bowel or kidney such as with severe diarrhea or emesis, salt-losing nephropathy or rarely hypergastrinemia. The ensuing hyponatremic hypochloremic alkalosis requires intravenous saline volume replacement and is usually easily corrected. It may be that excessive salt loss related to increased serum gastrin relates to reduced acid production in the stomach secondary to gastric resection. This can sometimes be reversed with carbonic acid (soda pop) with meals. The majority (77%) of the patients on clean intermittent catheterization have had at least one positive urine culture.
Our follow-up of patients who have undergone the demucosalized gastric flap procedure is limited to ten patients. All patients have tolerated the procedure well. Postoperative urodynamics will be necessary in order to demonstrate improvement in bladder capacity and compliance, but our early urodynamic data is very encouraging. For those patients who do not have a problem with recurrent urinary tract infections or have underlying renal insufficiency, this procedure may be an excellent alternative which avoids some of the complications of the traditional gastrocystoplasty.
Our experience with use of stomach for urinary reconstruction now extends to more than 80 patients treated at this institution. The diagnoses include neurogenic bladder, bladder exstrophy, exstrophy of the cloaca and urethral valves and ectopic ureter. We have performed augmentation and bladder replacement in adults and children although most of our experience is with the younger patients. Stomach can be used to totally replace the bladder, however, older male patients can experience urethral irritation. The advantages are little mucus, reduced infection and the ability to easily tunnel ureters or a conduit as a catheterizable stoma which make this a very appealing technique. We feel that in many clinical situations it is clearly advantageous over other tissues, particularly large and small bowel.
4. Thuroff, J.W., Alken, P.,
Engelmann, J., Riedmiller, H., Jacobi, G.H.
18. Nguyen, D.H., Bain, M.A., Salmonson, K.L., Ganesan, G.S., Burns, M.W., Mitchell, M.E.: The syndrome of dysuria and hematuria in pediatric urinary reconstruction with stomach. J Urol, 150:707, 1993.
back to internal pouches